Assessment of Youth Reproductive Health Programs in Ethiopia

Transcription

1 Assessment of Youth Reproductive Health Programs in Ethiopia April 2004 YouthNet Assessment Team Ed Scholl, Deputy Director for Technical Services, FHI/YouthNet Jane Schueller, Senior Technical Advisor, FHI/YouthNet Mulugeta Gashaw, Technical Consultant Abiye Wagaw, Youth Advisor, Ethiopian Youth Network Liya Wolde Michael, Youth Advisor, Ethiopian Orthodox Church This report was made possible through support provided by the United States Agency for International Development through its Cooperative Agreement with FHI for YouthNet, No. GPH-A The opinions herein do not necessarily reflect FHI or USAID policies.

2 In July 2011, FHI became FHI 360. FHI 360 is a nonprofit human development organization dedicated to improving lives in lasting ways by advancing integrated, locally driven solutions. Our staff includes experts in health, education, nutrition, environment, economic development, civil society, gender, youth, research and technology creating a unique mix of capabilities to address today s interrelated development challenges. FHI 360 serves more than 60 countries, all 50 U.S. states and all U.S. territories. Visit us at

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4 TABLE OF CONTENTS ACRONYMS/ABBREVIATIONS... v I. EXECUTIVE SUMMARY... 1 II. INTRODUCTION AND BACKGROUND... 2 Youth Reproductive Health Data... 3 HIV/AIDS in Ethiopia... 6 III. YOUTHNET ASSESSMENT TEAM VISIT... 8 About YouthNet... 8 Assessment Team Methodology... 9 IV. EXISTING PROGRAMS Government Programs and Policies NGO Programs Private Commercial Sector Donor Agencies V. REPEATED THEMES VI. POTENTIAL AREAS FOR YOUTHNET INVOLVEMENT ANNEXES ANNEX 1: Youth Reproductive Health Summary ANNEX 2: Organizations Visited and Individuals Interviewed ANNEX 3: Illustrative Questions for In-Country Interviews ANNEX 4: SWOT Analysis ANNEX 5: Description of Organizations Visited iii

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6 ACRONYMS/ABBREVIATIONS ABC ADA AHA AIDS ARH ARSH BCC BSS CBRHA CORHA CPS CSW DfID DHS DSW EC ECP EECMY EKHC EMDA EOC ESHE ESOG FBO FGAE FGC FHI FLE FY HAPCO HIV IEC IPO IPPF ISY IUD JICA LAM MOE MOH MYSC NFP NGO NOP Abstain, Be faithful or use a Condom Amhara Development Association Africa Humanitarian Action Acquired Immune Deficiency Syndrome Adolescent reproductive health Adolescent reproductive and sexual health Behavior change communication Behavioral Surveillance Survey Community-based reproductive health agent Consortium of Reproductive Health Associations Contraceptive Prevalence Survey Commercial sex worker Department for International Development Demographic and Health Survey German Foundation for World Population Emergency contraception Emergency contraceptive pills Ethiopian Evangelical Church Mekane Yesus Ethiopian Kale Hiwot Church Ethiopian Muslim Development Agency Ethiopian Orthodox Church Essential Services for Health in Ethiopia Ethiopian Society of Obstetricians and Gynecologists Faith-based organization Family Guidance Association of Ethiopia Female genital cutting Family Health International Family life education Fiscal year HIV/AIDS Prevention and Control Office Human Immunodeficiency Virus Information, education, and communication Implementing partner organizations International Planned Parenthood Federation In-school youth Intrauterine device Japanese International Cooperation Agency Lactational amenorrhea method Ministry of Education Ministry of Health Ministry of Youth, Sports, and Culture Natural family planning Non-governmental organization National Office of Population v

7 OIC OSSA OSY PAC PLWHA RH SDM SIDA SNNPR SO STI TOT UK UNICEF UNFPA USA USAID VCT WHO YRH YFS YLWHA Opportunities Industrialization Center Organization for Social Services for AIDS Out-of-school youth Post-abortion care Persons living with HIV/AIDS Reproductive health Standard days method Swedish International Development Agency Southern Nations, Nationalities, and People s Region Strategic objective Sexually transmitted infection Training of trainers United Kingdom United Nations Children s Fund United Nations Population Fund United States of America United States Agency for International Development Voluntary counseling and testing World Health Organization Youth reproductive health Youth friendly services Youth living with HIV/AIDS vi

8 I. EXECUTIVE SUMMARY USAID/Ethiopia invited a team from the YouthNet Program to carry out an assessment of current youth reproductive health programs and identify unmet needs and gaps, with the aim of further strengthening reproductive health programming for Ethiopian young people. The assessment was carried out by a team of five individuals from November 6-20, 2003 in the regions of Oromiya, SNNPR, and Amhara. The programs reviewed by the team included youth reproductive health programs supported by USAID/Ethiopia and the David and Lucile Packard Foundation in the three aforementioned regions. The team also visited public sector providers and met with personnel from the Ministry of Health and Ministry of Youth, Sports and Culture, as well as with UNFPA representatives, to learn about youth reproductive health initiatives supported by government institutions and other donors. The reproductive health problems faced by Ethiopian youth are tremendous and include gender inequality, sexual coercion, early marriage, polygamy, female genital cutting, unplanned pregnancies, closely spaced pregnancies, abortion, sexually transmitted infections, and AIDS. Lack of education, unemployment, and extreme poverty exacerbate and perpetuate the reproductive health problems faced by Ethiopian youth. Many existing programs are attempting to address these problems. Government support for youth reproductive health is strong, and the policy/legal framework in positive. Both the Ministry of Health and National Office of Population have special programs/initiatives addressing youth reproductive health. NGOs, both international and Ethiopian, are at the forefront of youth reproductive health programs in Ethiopia and provide a wide variety of services to youth. The Consortium of Reproductive Health Associations (CORHA) is the principal network of NGOs working in reproductive health in Ethiopia and is the chair of the Adolescent Reproductive Health Technical Subcommittee under the MOH National Reproductive Health Task Force. In addition to government and NGO programs, USAID and other donors also support private commercial ventures that provide reproductive health services, though these are not necessarily targeted to youth. These include private franchise clinics and contraceptive social marketing. Support for youth reproductive health programs in Ethiopia comes primarily from the Ethiopian government, USAID/Ethiopia, the David and Lucile Packard Foundation, UNFPA and a few smaller bilateral assistance programs. As a result of this assessment and the needs and gaps identified, YouthNet proposes to support youth reproductive health in Ethiopia by working primarily through CORHA in several initiatives, including the following: Development of an adolescent reproductive health strategic plan. Development of training curriculum and manual for youth reproductive health providers. Planning and implementation of an Adolescent Reproductive Health Forum. Assessment of existing family planning services to youth. Technical assistance in family life education to CORHA members. Technical assistance in building youth-adult partnerships among CORHA members. In addition, YouthNet proposes to work with both CORHA and the Ministry of Health in training trainers in contraceptive technology and family planning counseling for youth. 1

9 II. INTRODUCTION AND BACKGROUND Ethiopia is a nation of young people over 65% of its population is under 25 years of age 1 and a nation whose youth have profound reproductive health needs. Among the many sexual and reproductive health problems faced by youth in Ethiopia are gender inequality, sexual coercion, early marriage, polygamy, female genital cutting, unplanned pregnancies, closely spaced pregnancies, abortion, sexually transmitted infections (STIs), and AIDS. Lack of education, unemployment, and extreme poverty exacerbate and perpetuate the reproductive health problems faced by Ethiopian youth. Young people in Ethiopia also disproportionately suffer from the country s unsustainable population growth. Ethiopia s population of 71 million is projected to increase to 173 million by 2050, 2 becoming Africa s second most populous country after Nigeria. This rapid population increase will strain the government s ability to provide health care and education to young people and create conditions for even greater unemployment, poverty, and unrest. Besides unsustainable population growth, the specter of AIDS hangs heavy over Ethiopian youth. HIV prevalence is 6.6% in the adult population 3 and a large proportion of new HIV infections occurs in young people under 25 years of age. 4 A sign at the entrance to Addis Ababa University proclaims Get Addis Ababa University Degree, Not HIV Positive Certificate. Another underlying problem that negatively impacts reproductive health and retards overall development is pervasive gender inequality. The low status of women and girls and lack of male participation in family planning and AIDS prevention activities makes it especially difficult for reproductive health programs to achieve success. Societal inequalities between males and females, inequities within the family, harmful traditional practices against young girls, and the sugar daddy phenomenon are common in Ethiopia and are powerful forces that impede efforts to educate young women and men about reproductive health and provide them with needed services. Unless they are addressed, the reproductive health problems facing Ethiopian youth threaten to retard Young women in Ethiopia tend to marry early, marry older men and not use contraception. the country s development even further (Ethiopia was 168 out of 173 countries listed in the 2002 Human Development Report in order of development status) and bring greater instability to a country already suffering from high levels of unemployment, food insecurity, and widespread extreme poverty. Fortunately, there is consensus among the government, civil society, and international donors that youth reproductive health 5 needs are pressing and deserve greater attention and resources, though there is not always agreement on what strategies to pursue nor how to finance them. 1 Calculated from the U.S. Bureau of the Census, International Data Base generated at http: // 2 Population Reference Bureau World Population Data Sheet. Washington: PRB, Disease Prevention and Control Department, Ministry of Health and The Futures Group International (Policy Project). AIDS in Ethiopia. Fourth Edition. October HIV/AIDS Behavioral Surveillance Survey (BSS) Ethiopia 2002 (unpublished). 5 Youth is defined by YouthNet as encompassing young people years of age, while adolescents refer to the age group. 2

10 Youth Reproductive Health Data To understand the dynamics of youth reproductive health in Ethiopia the team consulted several nationally representative surveys of reproductive health, stratified by age, including the 2000 Demographic and Health Survey (DHS) 6 and the 2002 HIV/AIDS Behavioral Surveillance Survey (BSS), implemented by the Department of Community Health of Addis Ababa University. In addition, the team consulted the draft Contraceptive Prevalence Survey (CPS), conducted by Family Health International in 2003 in USAIDfunded project areas. Key data concerning youth reproductive health found in the DHS are presented below. Fertility General fertility rate (births per 1,000 women): total urban rural total urban rural 266 Percentage of 19 year old women who are or have been pregnant: 40 Family Planning Percentage of currently married women who know at least one contraceptive method: Percentage of currently married women who are using a contraceptive method: Percentage of unmarried sexually active women who are using a contraceptive method: Marriage Percentage of women ever married or in union: Median age at first marriage for women 25-49: 16 Fertility Preference Percentage of unmet need for family planning among currently married women: Central Statistical Authority and ORC Macro. Ethiopia Demographic and Health Survey Addis Ababa, Ethiopia and Calverton, Maryland: Central Statistical Authority and ORC Macro,

11 HIV and STIs Percentage of women who have heard of AIDS, by source: Community meetings 68 Radio 35 Schools/teachers 29 Friends/relatives 23 Percentage of youth who know of at least two programmatically important ways to avoid HIV/AIDS: Women 40 Men 60 Percentage of men who have heard of AIDS and been tested for AIDS: Percentage of men who have heard of AIDS and want to be tested: Sexual Activity Median age at first intercourse for women 25-49: * 16 Percentage of currently married youth, 20-24, with extramarital partners in the past 12 months:* Women 2 Men 6 Percentage of unmarried youth, 15-19, who had sex in the past 12 months: Women 4 Men 10 Women: 2 or more partners* 0.4 Men: 2 or more partners* 2 Percentage of unmarried youth, 20-24, who had sex in the past 12 months: Women 19 Men 30 Women: 2 or more partners* 2 Men: 2 or more partners* 9 Condoms Percentage use of condoms by women, 15-19, in last intercourse: With spouse or cohabiting partner 0 With non-cohabiting partner* 22 Percentage use of condoms by women, 20-24, in last intercourse: With spouse or cohabiting partner 0.5 With non-cohabiting partner* 14 Use of condoms by men, 20-24, in last intercourse: With spouse or cohabiting partner 0 With non-cohabiting partner* 32 When comparing these data with the 1990 National Family and Fertility Survey conducted by the Central Statistical Authority, one can see a drop in age-specific fertility rates for every age group except for the age * USAID core indicator for monitoring and reporting on HIV/AIDS programs. 4

12 group 15-19, which increased from 95 to 110 over the decade interval. Adolescent fertility is a growing problem in spite of overall increases in family planning use and overall reductions in fertility. Contraception among young people remains a very limited practice. Even among currently married women 20-24, the prevalence is a mere 7.5%, with injectables being the most common method used, followed by the pill (data on this page and following pages comes from 2000 DHS unless otherwise noted). Among married women 15-19, contraceptive prevalence is only 3.9%, with the pill being the most popular method used, followed by injectables. It is worth noting that IUDs and implants methods used for birth spacing among married women in other countries are not used at all by Ethiopian women 15-24, and used by less than 0.5 % of older women of fertile age. By contrast, use of contraception is much more common among sexually active unmarried youth, with four in ten reporting use of a method. The most common method used by these women is the pill, followed by the condom. Consistent with reports of household possessions (only 21% of households reported owning a radio and only 2% owned a television), only two out of ten young people, 15-19, reported hearing a family planning message on radio or television. Even fewer 8% reporting seeing a message about family planning in the print media (newspapers or magazines). Ethiopian women tend to marry early, at a median age of 16. The median age for first intercourse is also 16, suggesting relatively little premarital sex among women. In fact, 94% of sexually active adolescent girls are married. Men, on the other hand, have higher rates of premarital sex and their median age at first intercourse (20.3 years) is three years lower than their median age at first marriage (23.3 years). Among currently married women, four out of 10 women have an unmet need for family planning nearly all of it for spacing rather than limiting the next birth. A large majority of youth have heard about AIDS and the most common source for AIDS information is community meetings, followed by schools/teachers, radio, and friends/relatives. Knowledge of key prevention behaviors to avoid HIV/AIDS (abstinence, partner reduction, or use of condoms) is more common among young men than young women with only four out of 10 women able to name at least two key prevention behaviors. Currently, testing for AIDS is relatively uncommon (less than 2% of male youth have been tested), but a majority report that they would like to be tested, suggesting the potential for expanded use of voluntary counseling and testing (VCT) activities. Reported extramarital sexual activity among currently married youth is uncommon, with only 6% of men and 2% of women, 20-24, reporting one or more sexual partners other than their spouse or cohabiting partner. Reported sexual relations in the past 12 months by unmarried youth is more common for men than women, and increases with age. School attendance is a protective factor for reproductive health, yet less than a quarter of school-age girls in rural areas attend school. Condom use is extremely rare by young married men and women with their regular partner. Among noncohabiting partners use is higher: 32% of young men and 14% of young women used a condom at last intercourse. For male youth reporting sex with commercial partners, condom use is quite high 88% (BSS). 5

13 The HIV/AIDS BSS, conducted in 2002, contains a wealth of data that describe reported behaviors of both in-school youth (ISY) and out-of-school youth (OSY). In comparing these two groups, it is important to remember that the majority of rural girls and boys are not in school. As expected, the OSY report much higher levels of sexual activity, including higher levels of unprotected sexual activity. The majority of both ISY and OSY have knowledge about AIDS and how to prevent it and they also know where to obtain condoms. Over two-thirds reported that they had been exposed to messages about HIV/AIDS in the mass media. An important finding of the BSS is that ISY who had correct knowledge about HIV/AIDS prevention methods seemed to exhibit safer behaviors than the OSY, suggesting that education played an important role in converting knowledge into practice. The gap between knowledge and behavior was shown clearly by data for older OSY; this group knew that abstinence and monogamy were protective against HIV infection but were still likely to have premarital sex and more than one partner in the last year. The BSS also elicited information about reasons for youth engaging in risky sexual practices. The most common reason youth gave for not using a condom the last time they had sex with a non-regular partner was because they trusted their partner. HIV/AIDS in Ethiopia The AIDS epidemic in Ethiopia is a generalized one, though the HIV prevalence rate in the general population is far less than in many other Sub-Saharan countries of Africa. Data from 34 sentinel surveillance sites across Ethiopia indicate a national adult HIV prevalence rate of 6.6% with an estimated 2.2 million persons living with HIV/AIDS in Ethiopia is now among the most heavily affected countries, with 10% of the world s HIV infections (the sixth highest in the world). The highest prevalence of HIV is seen in the group years of age (12.1%). Data show that the number of females infected between years is much higher than the number of males in the same age group. This discrepancy is attributable to earlier sexual activity among young females with older male partners. 8 In one of the few studies to measure HIV seroprevalence among men from predominantly rural areas, over 71,000 army recruits were tested during 1999 and 2000 and prevalence was found to be 3.8%. 9 Prevalence rose with age, and was also higher among urban recruits. Prevalence was also higher among Orthodox Christians than Muslim recruits. Sign outside Addis Ababa University Children between the ages of five and 14 represent the fewest estimated number of HIV-infected persons and represent the window of hope for preventing the 7 Disease Prevention and Control Department, Ministry of Health and The Futures Group International (Policy Project). AIDS in Ethiopia. Fourth Edition. October Ibid. 9 Abebe Y, Schaap A, Mamo G, Negussie A, Darimo B, Woday D, Sanders E. HIV Prevalence in 72,000 Urban and Rural Male Army Recruits, Ethiopia. AIDS 2003; 17(12):

14 infection. If these boys and girls can be taught to practice the ABCs (abstain, be faithful, or use a condom) of prevention before they become sexually active, they can remain infection-free and eventually make a major impact on diminishing the epidemic. Hopefully, increased access to antiretroviral medications will become a reality in Ethiopia and further mitigate the infection and lessen its death toll. Given the fact that older youth have the highest HIV prevalence rates in the country, while younger youth represent the window of hope, youth are one of six target groups for preventing and controlling HIV/AIDS in Ethiopia, according to the HIV/AIDS Prevention and Control Office (HAPCO). 10 Other target groups include female sex workers, military personnel, farmers and pastoralists, long-distance truck drivers, and factory workers. A summary of the youth reproductive health situation in Ethiopia is presented in Annex Disease Prevention and Control Department, Ministry of Health and The Futures Group International (Policy Project). AIDS in Ethiopia. Fourth Edition. October

15 III. YOUTHNET ASSESSMENT TEAM VISIT The U.S. Agency for International Development Mission in Ethiopia recognizes that among Ethiopians, youth are at high risk of becoming pregnant and/or infected with STIs or HIV. Moreover, in order for program efforts to reduce the prevalence of unplanned pregnancy, STIs, and HIV, they understand the need to focus on youth and on those people most directly involved with young people, including parents, teachers, health workers, community leaders, and religious leaders. As a result, in September 2003, USAID/Ethiopia invited a team from the YouthNet Program to carry out an assessment of current programs and identify unmet needs and gaps, with the aim of further strengthening reproductive health programming for Ethiopian young people. The assessment of youth reproductive health programs was carried out by a team of five individuals from November 6-20, 2003 in the regions of Oromiya, SNNPR, and Amhara. The cities visited included: Addis Ababa, Jimma, Dessie, Kombolcha, Awassa, and Shashemane. The team consisted of two senior managers from YouthNet, Ed Scholl and Jane Schueller; an Ethiopian technical consultant, Mulugeta Gashaw; and two Ethiopian youth advisors, Abiye Wagaw and Liya Wolde Michael. Logistical assistance was provided by the FHI/Ethiopia office as well USAID/Ethiopia. They arranged for the team to meet with key informants from a variety of non-governmental organizations (NGOs), faith-based organizations (FBOs), donors, government ministries, and donor agencies. In addition, the team met with three groups of young people, two from the Ethiopian Orthodox Church and one from the Ethiopian Youth Network. The names of organizations visited and individuals interviewed are provided in Annex 2 and brief descriptions of each organization are included in Annex 5. About YouthNet YouthNet is a five-year cooperative agreement awarded by USAID/Washington in October 2001 to a team led by FHI, with partners CARE, USA; Deloitte Touche Tomatsu, Emerging Markets Group, Ltd.; Margaret Sanger Center International; and RTI International. The goal of the YouthNet Program is to improve reproductive health and HIV prevention behaviors among young people ages To achieve effective and sustainable youth programming, YouthNet aims to achieve the following three results (Rs): R1: Enhanced community and political support Strengthened community support for youth reproductive health and HIV prevention programs. This includes interventions at the policy level, with mass media, and with community-based volunteer organizations, including faith-based groups. R2: Improved knowledge, attitudes, skills, and behaviors Enhanced capacity of the education sector to reach in-school and out-of-school youth with knowledge and skills needed to foster and sustain health-affirming behaviors. 8

16 R3: Greater access to quality products and services Increased availability and quality of youthfriendly services and products to meet the reproductive health and HIV prevention needs of young people, including those who are most vulnerable. The YouthNet Program focuses on many different areas having to do with youth reproductive health and HIV prevention. These include: education, research, behavior change communication (BCC), private sector involvement, policy support, faith-based initiatives, and knowledge management. The Program also has two important cross-cutting themes which emphasize gender equity and youth participation. Monitoring and evaluation are key components of YouthNet programming so that achievements towards program goals and objectives can be measured. Research to advance state-of-the-art programming for youth, and information sharing across a wide range of programs are two additional components of the YouthNet Program. YouthNet seeks to complement programs already being successfully implemented by identifying gaps, promoting sharing of information and skills, and helping to address unmet needs. As with other FHI programs, YouthNet s emphasis is on collaboration with local implementing partners and building the capacity and ownership of programs for sustainable interventions. Assessment Team Methodology To conduct an effective assessment of adolescent reproductive health programs, it was important for the team to first gain an understanding of the general context of reproductive health in Ethiopia. The process for doing this was to conduct a SWOT (strengths, weaknesses, opportunities, and threats) analysis based on the desk review carried out prior to arriving in Ethiopia and information and materials obtained during meetings with NGOs, FBOs, Government ministries, youth, USAID Cooperating Agencies, and donor agencies. The results of this analysis are presented in Annex 4. The basic methodology used by the YouthNet Assessment Team to gather information in country was a question and answer format, with the goal of identifying what is happening in Ethiopia with regard to youth reproductive health, what the gaps and challenges are, and what stakeholders viewed as possible solutions to the existing situation in order for current programming to have sustainable impact. The primary goal of the meetings with NGOs, FBOs, Government ministries, and donor agencies was to actively listen to what they are doing on the ground. A set of generic questions was used to stimulate and guide discussions. An illustrative outline of these questions is provided in Annex 3. Every meeting started with an introduction/ overview of YouthNet as well as the purpose of the visit and included questions on what the organizations/ individuals saw as the most critical problems and needs of youth, possible solutions, and priority areas for programs and services. The team also held focus group discussions with three groups of youth to ascertain norms and practices among various communities in Ethiopia. An illustrative outline of the questions asked at these meetings is also provided in Annex 3. Finally, the team met periodically during the assessment with USAID/Ethiopia staff and provided an end of assessment debriefing to the Mission and various partners working in the field of youth reproductive health. 9

17 IV. EXISTING PROGRAMS There are currently a great many reproductive health programs targeting youth in Ethiopia, including programs run by NGOs, government agencies, and private commercial providers. The purpose of the YouthNet consultancy was to conduct an assessment of youth reproductive health programs supported by USAID/Ethiopia and the David and Lucile Packard Foundation that are implemented by Ethiopian and U.S. NGOs in three regions of the country (Oromiya, SNNPR, and Amhara). Though our assessment was thus limited to specific regions and to implementing agencies funded by USAID/Ethiopia and the Packard Foundation, we also visited public sector providers and met with personnel from the MOH and MYSC, as well as with UNFPA representatives, to learn about youth reproductive health initiatives supported by Government institutions and other donors. A summary of the service delivery programs we observed that offer reproductive health care to youth is provided in the table on the following page, categorized by the type of services provided. More detailed information about the services provided by each of these organizations, as well as information about other organizations visited that provide support or funding for youth reproductive health programs, can be found in Annex 5. A brief summary of the types of existing programs and policy initiatives that support youth reproductive health, as well as the donors that fund them, follows. Computer-assisted learning for at-risk youth at OIC Center 10

18 Types of Youth Reproductive Health Service Delivery Programs Observed Organization Location Observed CBRHA General Clinic Youth Centers/Clubs Youth - Friendly Clinics Peer Ed. School-based HIV/RH Education Income Gen./ Vocational Training Mass Media VCT Care and Support/ OVC MOH Health Center Kombolcha MOH District Hospital Borumeda Pathfinder Private Franchise Clinic (Packard funded) Dessie Family Guidance Association of Ethiopia (Packard funded) Addis Ababa Dessie Awassa Jimma Organization for Social Services for AIDS (Packard and UNFPA funded) Dessie Awassa Jimma Amhara Development Assoc. (Packard funded) Dessie Ethiopian Kale Hiwot Church (Pathfinder funded) Awassa Opportunities Industrialization Centers (Packard and USAID/W funded) Kombolcha Jimma Africa Humanitarian Action (Pathfinder funded) Shashemane Jimma Ethiopian Evangelical Church Mekane Yesus (Pathfinder funded) Kombolcha Save the Children USA (Packard funded) Addis Ababa

19 Organization Location Observed CBRHA General Clinic Youth Centers/Clubs Youth - Friendly Clinics Peer Ed. School-based HIV/RH Education Income Gen./ Vocational Training Mass Media VCT Care and Support/ OVC Ethiopian Orthodox Church Addis Ababa Jimma CARE/Ethiopia Addis Ababa Ethiopian Muslim Development Agency (Pathfinder funded) Jimma 12

20 Government Programs and Policies Government support for youth reproductive health (YRH) is fairly strong and reflects the concern on the part of Government authorities to prevent unintended pregnancies, STIs, and HIV among youth. The policy/legal framework for YRH is also positive, as previously noted. Examples of governmental support for YRH include the adoption of the 1993 population policy (still in effect today), passage in the Parliament of the Family Law (raising the minimum age of marriage, among other supportive articles), and revision of the penal code, decriminalizing the advertisement and sale of contraceptives. Additional support for YRH by the Government has been in the form of advocacy, sectoral guidance and policy formulation, inter-agency coordination, leadership development, and school-based FLE. The principal government ministries and offices that provide youth reproductive health education or services include the Ministry of Health, the National Office of Population, the Ministry of Youth, Sports, and Culture, the HIV AIDS Program and Control Office, and the Ministry of Education. The assessment team particularly focused on the Ministry of Health and the National Office of Population; a brief summary of these two institutions follows. 1. Ministry of Health (MOH) The MOH has been pursuing various adolescent reproductive health initiatives under its Family Health Department. Under its National Reproductive Health Task Force, it has formed an Adolescent Reproductive Health Technical Subcommittee to coordinate activities related to YRH and oversee implementation of its YRH program. Activities carried out by the Family Health Department include training on YRH for providers from the various regions, conducting workshops on YRH issues, and development and distribution of IEC materials on YRH. In 2002, the Family Health Department of the MOH developed the Five-Year Action Plan for Adolescent Reproductive Health in Ethiopia ( ). The plan aims to increase access and utilization of YRH services by youth, and increase information and knowledge about reproductive health that leads to positive behavior change by youth. The Five-Year Action Plan also identifies the need to develop a YRH strategy for the country, which the MOH is currently undertaking. As such, an adolescent reproductive health strategy will also soon be developed which will be part of the overall National Reproductive Health Strategy. Several key informants told the team that the MOH Action Plan has not received adequate attention by the Government and has not progressed far due to a lack of financial support to implement it. MOH facilities - be they hospitals, health centers, or rural health posts - are often referral sites for NGO providers, especially the community-based reproductive health agents (CBRHA) affiliated with various NGOs. These referrals, some of which are for youth, are for clinical family planning methods, diagnosis and treatments of STIs, and VCT, among other services. According to some of the key informants that the team met with, YRH services remain underdeveloped in MOH establishments. They are not particularly youth-friendly and youth must access services in them in the same manner as adults. Many youth are embarrassed to do so given the stigma associated with unmarried women being sexually active and, therefore, youth tend not to receive reproductive health services from MOH establishments. This perception was borne out by the team s visit to MOH facilities in the area of Dessie. 13

21 2. National Office of Population (NOP) The NOP was established in 1993 following the country s adoption in the same year of an explicit population policy. Several strategies outlined in the 1993 population policy, which the NOP is charged with helping to implement, pertain specifically to youth. These include reducing the high attrition rate of females in the educational system, providing career counseling in secondary schools and universities, establishing youth reproductive health counseling centers, and raising the minimum age of marriage for girls from 15 to 18. This latter aim was achieved with the recently passed Family Law. The NOP is an active participant in both USAID (through Pathfinder) and Packard Foundation-supported youth reproductive health programs. The Reproductive Health Women and Youth Affairs Department of the NOP chairs a technical committee that reviews and does final selection of Pathfinder subgrantees. With Packard, the same department of the NOP participates in quarterly grantee meetings. The NOP also collaborated in the recently developed National Youth Policy, presented to the Council of Ministers by the MYSC. In January 2000, the NOP launched its National Population Information, Education and Communication and Advocacy Strategy: , with technical assistance provided by Johns Hopkins University/Center for Communication Programs. This ambitious strategy identified twelve thematic areas to be addressed through mass media, print media, traditional media, institution-based communication, formal and non-formal education, and counseling. Youth are among the primary audiences for nearly all of the twelve thematic areas and one area Youth and Development is entirely focused on the needs of youth. Unfortunately, we were informed that much of this strategy has not been implemented, owing in part to disagreements between the NOP and MOH over management of the reproductive health component of the strategy. The primary donor for implementation of the strategy UNFPA reportedly withdrew its support for the reproductive health component of the strategy but continues to fund implementation of the population and development component. Another initiative that the NOP is actively involved in is developing leadership in the country in the area of population and reproductive health. A steering committee emerged in 2001 with the aim of fostering in-country leadership development. The NOP is currently the chair of the taskforce charged with implementing the recommendations made by the steering committee. NGO Programs NGOs, both international and Ethiopian, are at the forefront of adolescent reproductive health programs in Ethiopia and were the subject of the majority of the team s visits, interviews, and observations during our time in-country. The team s assignment consisted of assessing youth reproductive health programs supported by USAID/Ethiopia and the Packard Foundation in three regions of the country. The NGOs supported by USAID/Ethiopia that were visited by the 14 OSSA affiliated Anti-AIDS club members in Awassa

22 team included Pathfinder International and many of its sub-grantees, and Save the Children USA. The Packard Foundation-supported NGOs that were visited were many local NGOs, including one of the largest NGOs in the country the FGAE (also the IPPF-affiliate in Ethiopia). As shown in the table presented earlier ( Types of Youth Reproductive Health Service Delivery Programs Observed ), these NGOs provide a wide variety of services to youth. More detailed information about each of the NGOs is provided in Annex 5. The NGOs supported by USAID/Ethiopia and the Packard Foundation are all members of a consortium known as CORHA the Consortium of Reproductive Health Associations. FGAE Youth Center in Addis Ababa There are 65 member organizations of CORHA, including both international and local NGOs. CORHA s plan includes four principal strategies: interagency coordination, advocacy, capacity building, and sustainability/fundraising. To facilitate its work in advocacy, CORHA began a national reproductive health advocacy network in Adolescent reproductive health is one of the advocacy issues being addressed by the network. CORHA receives financial assistance from USAID through Pathfinder (for institutional strengthening) and FHI (for research and monitoring/evaluation). The Packard Foundation also provides assistance to CORHA for its advocacy work. Save the Children- trained peer educator in front of classroom 15

23 CORHA is the chair of the Adolescent Reproductive Health Technical Subcommittee under the MOH National Reproductive Health Task Force. They plan to soon have a forum on adolescent reproductive health with working groups formed on the issues of sustainability, BCC, advocacy, service delivery, and research and monitoring/evaluation. Private Commercial Sector The two types of programs involving the private commercial sector that the team observed were private franchise clinics and commercial social marketing of contraceptives. 1. Private Franchise Clinics Through its grant funds from the Packard Foundation, Pathfinder International is expanding reproductive health services by involving the private for-profit health sector. This program has established links with 96 franchise clinics that provide general medical care and reproductive health care to low-income populations in the communities where they are located. Adolescents are sometimes among the clients served by these clinics, though for the most part they serve adult clients. Pathfinder provides training in contraceptive provision to the franchise clinic providers, including training in tubal ligation, IUD insertion, and emergency contraception. Training in post-abortion care is also provided, as well as training in reproductive health counseling. In addition, Pathfinder provided contraceptives to these private providers at a discounted price. One of the challenges faced by Pathfinder is to motivate the franchise clinic providers to talk about reproductive health issues with their clients and offer them contraceptives (for which the providers can charge very little) when they can make much more money by attending to sick patients with medical problems for which they can charge much more. 2. Contraceptive Social Marketing USAID/Ethiopia, DfID, the Packard Foundation, and the Government of the Netherlands all support a contraceptive social marketing program in Ethiopia managed by DKT International. This program markets the Confidence brand of Depo-Provera, Prudence oral contraceptives, and Trust condoms. According to DKT, they account for 90% of all condoms distributed in Ethiopia (68 million in 2002). DKT sells their contraceptive products at a discount to both commercial pharmacies and NGOs, who then offer them to the public at agreed-upon low prices. The price to the public for a three-pack of Trust condoms, for example, is 0.25 birr, or approximately US$0.03. The team saw DKT products everywhere it traveled, suggesting widespread distribution and marketing. Interestingly, the team also found DKT products, particularly Trust condoms, in MOH facilities. According to one MOH administrator interviewed, DKT condoms are purchased by the district (woredas) HIV councils and then given to MOH health centers, presumably due to stockouts in the USAID and UNFPA-donated condoms provided to the MOH. Besides marketing contraceptives, DKT also includes A (for abstinence) and B (for be faithful) messages in its advertising. An attractive ABC poster developed by DKT has had widespread distribution in the country. 16

24 Donor Agencies There are numerous youth reproductive health programs supported by external donor agencies, both bilateral and multilateral, as well as foundations such as the Packard Foundation, discussed previously. The two major external donor agencies that support youth reproductive health are USAID/Ethiopia and the United Nations Population Fund. 1. USAID/Ethiopia USAID/Ethiopia is the largest bilateral donor supporting reproductive health in Ethiopia. Through its Essential Services for Health in Ethiopia (ESHE) Strategic Objective (SO), the Mission supports many reproductive health and HIV/AIDS activities, primarily in the regions of Oromiya, Amhara, and SNNPR. USAID s principal contractors and grantees implementing reproductive health activities in Ethiopia include Family Health International, Pathfinder International, Save the Children USA, Population Services International, John Snow International, Macro International, the University of North Carolina, and DKT International. Youth are a target group of many of the USAID-supported activities, particularly the program administered by Pathfinder International. Through Pathfinder and USAID s other partners, over 150 adolescent service sites are currently being supported. HIV/AIDS activities supported by USAID also target youth, as does an education program that is establishing anti-hiv/aids school clubs. 2. United Nations Population Fund (UNFPA) UNFPA is currently implementing its fifth program of assistance to Ethiopia, with a program fund of $24.5 million for the period UNFPA s assistance program consists of three major components: reproductive health, including family planning and sexual health; population and development strategies; and advocacy. Within its reproductive health component, UNFPA lists seven critical, interrelated reproductive health concerns: safe motherhood; adolescent reproductive health; STIs; HIV/AIDS; family planning; postabortion care; and harmful traditional practices. One of the ways UNFPA supports adolescent reproductive health is by funding NGO activities. In addition to its financial support for such activities, UNFPA is active in adolescent reproductive health policy and advocacy and is one of many institutions assisting the MOH in the development of its adolescent reproductive health strategy. UNFPA also participates in the Adolescent Reproductive Health Technical Subcommittee, chaired by CORHA. 17

25 V. REPEATED THEMES Numerous gaps and challenges were identified throughout the assessment team s visit, and many repeated themes emerged from the discussions held with NGOs, FBOs, Government ministries, donor agencies, and youth groups. These themes are not necessarily recommendations, but rather observations made and recurring issues heard. In no particular order, each theme and its brief description are outlined below: Reproductive health services and contraceptive supply/logistics need to be improved Despite an increase in the number of health facilities, there has been little or no improvement in the quality of reproductive health services in Ethiopia. Basic drugs, supplies, and trained personnel are in short supply, which is often exacerbated by an inefficient use of resources, poor management systems, and limited capacity to deliver quality services. Distribution of facilities remains partial to urban areas, which is of great concern since Ethiopia is 85% rural. As mentioned under the SWOT analysis, contraceptive stockouts are also common due to a poor logistics system. Although there is a growing demand for family planning methods, a major problem is that of irregular and inadequate contraceptive supplies. Programs to increase access to contraceptives could be enhanced through greater social marketing and NGO and private-sector delivery of services. Improving the quality of reproductive health services through systems strengthening, e.g., management, logistics, and supervision, will also help to meet the demand for family planning by youth and adults. Increased use of chat among youth is associated with unprotected sex A majority of the key informants interviewed expressed concern regarding the increased use of chat by young people. In particular, they talked about the chain of events that commonly accompanies use of the drug. Adults and youth alike mentioned that frequent chat-chewing often leads to increased alcohol use, which ultimately leads to young people having unprotected sex. Many informants recommended that youth centers and youth-focused programs need to better address this problem by teaching young people about the consequences and dangers of drug and alcohol use and their effects on the lives of young men and women. Youth want more recreational/sports facilities and libraries/reading corners Although most youth centers and programs offer some sort of recreational activity for young people, and many of them have a small space appointed for reading/studying, all of the young people and many of the adults interviewed stated that this is an area that requires even greater attention. Such facilities could help to keep young people active, provide them with alternatives to sexual activity, and give them a place where they can gather to talk, vent, brainstorm, learn, and share with each other their experiences. Efforts to reduce harmful traditional practices must continue Among the informants interviewed, most acknowledge great concern about harmful traditional practices, such as early marriage, FGC, and marriage through abduction and/or rape. Given their widespread prevalence, especially in rural areas, all of these issues require attention. Although the age of marriage was recently raised to 18, it is highly disregarded throughout the country, which means that early marriage continues to occur frequently and is often accompanied by abduction and/or rape. FGC is also a grave concern for Ethiopia with an estimated incidence of 80% (DHS). Although the Government is working towards its eradication, and criminal and civil court laws are being revised to make it illegal, few efforts have been widespread enough to have any sort of real impact. There is great desire on the part of all organizations interviewed to further reduce harmful traditional practices, but many are already overburdened and/or under-funded, thus, it is often a challenge to explicitly include this component in their programs. Reducing provider bias against youth would help to improve access to services The reproductive health needs of adolescents are immense, but so are the obstacles young people face, especially when 18

26 they try to obtain health services. Throughout the team s visit, the need for more youth-friendly services was often raised, and it was noted that very few youth clinics exist in Ethiopia, especially in rural areas. However, beyond the need for greater numbers of facilities, there is an even greater challenge to be overcome which deals with reducing health worker bias against serving youth. The knowledge and beliefs of providers play a large role in the kind of information and services a young man or woman receives. Those that have a negative effect include: judgmental attitudes toward adolescent sexual activity, inadequate knowledge of up-to-date scientific information related to contraceptive safety and use for adolescents, prejudice against unmarried youth, requirements for unnecessary medical tests and pelvic exams, and lack of understanding of national health policies that may allow for provision of information and services to young people. Young people are reluctant and uncomfortable discussing reproductive health-related issues Given its conservative culture and religion, Ethiopia is faced with an overwhelming challenge to assist its young people (and society, in general) to openly discuss issues related to sex, sexuality, family planning, reproductive health, STIs, and HIV/AIDS. As a result, most youth lack basic knowledge of reproductive anatomy and physiology, how pregnancy or STIs/HIV occur, how to prevent them, and where to obtain information and services. Parents and adults also feel ill-prepared, uncomfortable, or awkward talking about sex with their children. This cultural unwillingness and embarrassment to discuss such issues presents a great barrier to youth and youth reproductive health programs to reduce the number of unintended pregnancies and STIs/HIV in Ethiopia. It means youth are unable to access the knowledge and skills needed to make healthy decisions, and it limits their ability to seek contraception or STI/HIV/AIDS services, when necessary. Stigma around discussing sex and sexuality needs to be reduced, barriers to communication must be broken down, and new behaviors need to be formed in order to open dialogue at all levels of society on sensitive issues related to adolescent reproductive health. Youth want their voice to be heard There are many organizations working for youth in Ethiopia; however, not all of these groups are working with youth. For example, only a very limited number of organizations interviewed stated that they include youth in their decision-making process. Young people are assets and bring creative ideas to programming. Therefore, it is crucial to advance youth empowerment and involvement in programs that are targeted specifically for them. Use of the media (radio, television, and print) could be very instrumental in raising awareness among young people of the need for them to take charge of and protect their reproductive health. Youth representation in decisionmaking could be enhanced through the creation of youth advisory councils in all youth-serving organizations or by including youth representatives on boards. By sharing power between youth and adults, youth themselves will become empowered to be full partners in curbing unplanned pregnancies and stopping the spread of STIs/HIV. If they own it, youth will make it work. Adolescent reproductive health policies need to be funded, put into action, monitored, and evaluated In recent years, the MOH, MYSC, and others have made great policy strides toward meeting the needs of youth with regard to their reproductive health. For the MOH, various initiatives are currently underway as part of its Five-Year Action Plan for Adolescent Reproductive Health in Ethiopia ( ). The plan aims to improve access and utilization of reproductive health services by youth and increase information and knowledge about reproductive health that leads to positive behavior change among youth. The MYSC has recently completed a National Youth Policy which is now before the Council of Ministers for adoption. It is recognized by most that both of these policies go a long way in trying to meet the reproductive health needs of adolescents; however, there is great concern among NGOs, FBOs, and donor agencies about how these policies will be put into action, monitored, and evaluated. Many worry that simply having a policy will not be enough and that more funding must be allocated towards their implementation. Furthermore, information building will need to take place at all 19